Alarming stories on the radical effects produced by hospital downsizing are reaching a critical mass in the popular press and professional journals. Attention has been given to concerns arising from the use of non-nursing personnel for patient care and to the fears nurses experience regarding their own jobs. Contemporary accounts view these changes in patient care as novel. History suggests otherwise. Whether the complaint is too many or too few, since the inception of the original schools of nursing, there has been little satisfaction with the number or site of employment of nurses working at any point in time. The goal of this study will be to trace twentieth century employment arrangements nurses have utilized to provide patient care and maintain reliable working conditions. This study will use critical social historical analysis of the period between 1923-1963 to describe the process by which nurses and hospitals evolved from a private duty/student system to a formal nursing service composed of graduate staff nurses. By examining the extent to which nurses were engaged by patients, their working conditions, and the factors associated with the decline of private duty, a thorough analysis will be presented of how sick individuals obtained nursing services and how these involved in delivering care organized their working lives. Knowledge of this critical period in nursing history can illuminate and place in historical context our current difficulties adjusting to a changing health care system as we cross the bridge to 21st century nursing.